Insurance Application Questionaire

To start, what effective date would you like for this policy?
Date:    ASAP

1 Please tell us a little bit about yourself
*1.1 What is the name of your company?

*1.2 What is your name?
First Name:   MI:   Last Name:

1.3 What is your email address?

1.4 Under what legal structure is your business operating?

*1.5 What is your business mailing address?
City:     State:     Zip:

*1.6 What is your phone number?
() – – Ext.

*1.7 What is your Federal Tax ID number?

2 Please tell us about your business
2.1 How many years have you been in business under this name?   

2.2 How many years of experience do you have in this industry?   

2.3 How many employees do you currently have?   

2.4 What are your projected total sales receipts for the next twelve months?   

2.5 What is the company’s projected total payroll for the next twelve months?  

2.6 Please provide a laymen’s description of your business operations. Please use at least 15 words.

Copyright © 1995-2006 United Agencies, Inc. All Rights Reserved.
Partner | Licenses | Privacy Policy | Terms of Use